Volunteer Application
Bedford County Department of Fire & Rescue


Which division would you like to apply for?

?

Primary area of interest?
APPLICANT INFORMATION

First Name
MI
Last Name
Suff
Street

   
City
State
Zip
 
Home Phone
Work Phone
 
Email
SSN#
VA Driver's Lic#
mm/dd/yyyy
Date of Birth

Occupation

Place of Employment

Previous Experience or Memberships (Fire or Rescue or Military)

Certification and Levels of Training
Please list any physical, mental or emotional disabilities
Previous Fire or EMS affiliation or experiences
 
EDUCATION

Name of High School

Highest grade completed

 

Name of College

Years Completed


REFERENCES
List two persons who are not related to you who know your qualifications or your character
Name Address Phone

BACKGROUND CHECK
Drug Screen/Physical
Are you willing to have a yearly drug screening and physical?
Convictions
Other than violations committed as a juvenile (under 18 years of age),
have you ever been convicted of any violation(s) of the law, felony or misdemeanor?

If yes, please explain
 

Traffic Violation
Have you ever been
Convicted of any traffic violation?

If Yes, Please explain

 

CPS Complaint
Have you ever been a subject of a complaint
through the Child Protective Services?

If yes, please explain
 

CPS Founded Complaint
Have you ever been party of a founded complaint filed with Child Protective Services?

If yes, please explain
 

 

 

Why?

Please use this space to explain why you would like to be a Fire or Rescue Volunteer

CERTIFICATION

By clicking on the Certify Checkbox below, I certify that all information provided on this application is true, accurate and complete. In addition, I understand that this certifcation authorizes the Department of Fire & Rescue to investigate my criminal and motor vehicle operation background to verify the information in correct.

The information supplied by me in this application is complete and is true to the best of my knowledge and belief. I understand that misstatement of material facts will cause forfeiture of all my rights to any employment or result in dismissal from employment.

In addition, I grant permission to the Virginia Division of Motor Vehicles to provide copies of my driving record to the Bedford County Department of Fire and Rescue for evaluation purposes only.

All information provided to the Department of Fire and Rescue will remain confidential and will not be released to outside entities except as required by law.

Use the scroll arrows to REVIEW YOUR APPLICATION. Make any change desired by typing over the old information.  You will be required to sign a paper copy if you are interviewed. This will become an official, permanent record. 
     You may print this page before submitting if you wish, by clicking the Print button.  
Please remember to click the Submit button below after printing! 
   

Be sure to check the certification box above.   You will not be able to submit your application without certification.